The Healthcare Safety Investigation Branch ("HSIB") is the independent organisation that has been set up to investigate incidents for the purpose of learning and improving safety in the NHS.
I have been closely following the developments and growth because I think it is such a good step towards sharing knowledge arising out of incidents nationally from an independent perspective. I am optimistic because when I was in the railway industry as a safety investigator, I saw first hand how much the Railway Accident Investigation Branch("RAIB") (HSIB's equivalent) contributes to the industry.
As the Williams review referred to yesterday (11 June 2018), the railway is slightly different because deaths happen a lot less frequently - but the RAIB contributes to learning from near misses and Train Operating Companies across the country all gain a bit of insight into the things that are going wrong elsewhere so it gives you such a good perspective. Very rarely did we say "oh that wouldn't happen in our organisation" or "the recommendations don't apply to us".
So what is the current position?
* HSIB is up and running;
* investigators have been recruited and according to lots of activity on Twitter, lots of training and support has been provided to investigators, particularly about looking for the contribution of human factors to incidents;
* the first reports are due to be published shortly so it will be good to see an example of the product;
* the aim is that maternity incident investigations will have national coverage by March 2019 - which is pretty impressive, if slightly optimistic;
what am I looking out for?
* I'm hoping that some incidents identify national or regional issues / trends / learning points;
* I'm hoping that, when reports are produced, the NHS welcomes and engages with the recommendations;
* I'm interested to see the types of things that HSIB pick out as being things to investigate;
* I'm interested to see how reports are shared, circulated and reviewed by those not directly involved;
* how HSIB reports might help improve knowledge about practical difficulties and contextual factors impacting patient safety;
* how those asked to assist with investigations engage / co-operate - their function will only work if people and organisations are open - but will culture prevent this? I hope not;
* I am hoping that the opportunity for this organisation to make an impact isn't affected by aims that are too ambitious. According to HSJ, HSIB aim to cover 1000 incidents per year.
It will adopt a phased roll out of the programme with the aim of covering all trusts in England by March 2019. This is expected to cover around 1,000 incidents a year.